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Helping Patients Manage Their Chronic Conditions Helping Patients Manage Their Chronic Conditions June 2005 Helping Patients Manage Their Chronic Conditions Prepared for: CALIFORNIA HEALTHCARE FOUNDATION Authors: Thomas Bodenheimer, M.D. Kate MacGregor, M.P.H. Claire Sharifi June 2005 About the Authors Thomas Bodenheimer, M.D., is an adjunct professor in the Department of Family and Community Medicine at the University of California, San Francisco. Kate MacGregor, M.P.H. is the research director of the Action Plan Project in the Department of Family and Community Medicine at the University of California, San Francisco. Claire Sharifi is a research assistant in the Action Plan Project. About the Foundation The California HealthCare Foundation, based in Oakland, is an independent philanthropy committed to improving California’s health care delivery and financing systems. Formed in 1996, our goal is to ensure that all Californians have access to affordable, quality health care. For more information, visit us online (www.chcf.org). This report was produced under the direction of CHCF’s Chronic Disease Care Program, which seeks to improve the health of Californians by working to assure those with chronic diseases receive care based on the best scientific knowledge. Visit www.chcf.org/programs/ for more information about CHCF and its programs. ISBN 1-932064-84-2 Copyright © 2005 California HealthCare Foundation Contents 4 Executive Summary 6 I. Introduction 8 II. Five Strategies for Clinical Practice Collaborative Decision Making: Establishing an Agenda Information Giving: Ask, Tell, Ask Information Giving: Closing the Loop Collaborative Decision Making: Assessing Readinesss to Change Collaborative Decision Making: Goal Setting 16 III. Impact on Behaviors and Clinical Outcomes 20 IV. Summary 22 Endnotes Executive Summary SELF-MANAGEMENT SUPPORT IS THE ASSISTANCE caregivers give patients with chronic disease in order to encour- age daily decisions that improve health-related behaviors and clinical outcomes. Self-management support can be viewed in two ways: as a portfolio of techniques and tools that help patients choose healthy behaviors; and a fundamental transfor- mation of the patient-caregiver relationship into a collaborative partnership. The purpose of self-management support is to aid and inspire patients to become informed about their conditions and take an active role in their treatment. True self-management sup- port involves both patient education and collaborative decision making. This document describes five interlocking strategies that help caregivers work within the collaborative model. The five strategies are: I Collaborative decision making: establishing an agenda; I Information giving: ask, tell, ask; I Information giving: closing the loop; I Collaborative decision making: assessing readiness to change; and I Collaborative decision making: goal setting. In addition, this document reviews literature describing the effectiveness of self-management support interventions. Among the conclusions from that review: I Self-management support does improve health-related behaviors, and as a result, clinical outcomes. I The self-management support intervention for which the evidence is strongest is a collaborative interaction between caregiver and patient. I Providing information is a necessary—but not suffi- cient—intervention to improve health-related behaviors or clinical outcomes. I A collaborative relationship between caregiver and patient must be added to information giving in order to improve behaviors and outcomes. 4 | CALIFORNIA HEALTHCARE FOUNDATION Providing self-management support presents a major challenge to primary care practices because self-management support takes time— perhaps the most limited resource in primary care. Physicians cannot provide adequate self- management support amid the many competing agendas of a 15-minute office visit. Thus, primary care practices must create teams in which non-physician caregivers are trained to work with physicians in offering self-manage- ment support, from information giving and collaborative decision making to assessing patients’ readiness to change health-related behaviors and setting behavior-change goals. Helping Patients Manage Their Chronic Conditions | 5 I. Introduction At a neighborhood health fair, Felicidad Rojas was found to have an elevated cholesterol level. Her physician, whom she had seen for eight years, had never checked her choles- terol. She went to the library and used the Internet to learn about cholesterol, then changed her diet and began an exercise program. Within three months, her cholesterol level was normal. Don Rich, a corporate executive who had been receiving his health care from one of the nation’s leading multispe- cialty groups, was found to have elevated cholesterol during his routine yearly screening. He was offered a series of visits with the nutritionist, a free membership at a local gym, regular lab follow-up, and cholesterol-lowering medication. He did not follow the diet, did not go to the gym, and took the pills about once a week. His cholesterol remained high. These examples illustrate the crucial role that patients play in the treatment of chronic disease. Felicidad Rojas experienced inadequate medical care but excelled at self-managing her cholesterol problem. Don Rich had the best medical care but was not interested in self-managing his cholesterol problem. How people self-manage their chronic health problems is often more important than the medical care they receive. Most peo- ple need assistance in learning to manage a chronic condition; an essential function of primary care is to help people become good self-managers. Self-Management Support All patients with chronic conditions self-manage every day: They decide what to eat, whether to exercise, if and when they will take medications. The important question is whether they make changes that improve their health-related behaviors and clinical outcomes. To help such patients succeed, health care providers are explor- ing what is known as self-management support. This report examines the importance of self-management support, outlines some of the approaches caregivers are using, and considers the 6 | CALIFORNIA HEALTHCARE FOUNDATION evidence that self-management support can approach that provides information that patients improve health-related behaviors and clinical are interested in learning. outcomes. Several key characteristics illustrate the shift from Self-management support can be approached two a traditional to a collaborative interaction ways: as a series of techniques or tools that between caregiver and patient. encourage patients to choose healthy behaviors I In traditional interactions: or as a fundamental shift in the patient-caregiver • Information and skills are taught based on relationship. Rather than having caregivers, par- the caregiver’s agenda; ticularly physicians, tell patients what to do to • There is an assumption that knowledge improve their health, the new model is designed creates behavior change; to build a partnership between caregiver and • The goal is compliance with the caregiver’s patient, with a shared responsibility for making advice; and and carrying out health-related decisions. Caregivers provide patients expertise and tools; • Decisions are made by the caregiver. patients are responsible for their day-to-day I In collaborative interactions: health decisions. • Information and skills are taught based on The purpose of self-management support is to the patient’s agenda; help patients become informed about their con- • There is a belief that one’s confidence in ditions and take an active role in treatment. Self- the ability to change (called “self-efficacy” management support involves two interrelated by behavior researchers), together with activities: knowledge, creates behavior change; I Providing information about patients’ • The goal is increased confidence in the chronic conditions (helping patients to ability to change, rather than compliance become informed). with a caregiver’s advice; and • Decisions are made as a patient-caregiver I Working in partnership with patients to partnership. make medical decisions, including whether the patients agree to take medications rec- Is self-management support pertinent to all ommended by clinicians, whether patients patients, or are some patients by nature passive, wish to undergo diagnostic or surgical pro- poorly motivated, and unable to self-manage? cedures, and which health-behavior-related Some patients are by nature passive, but care- goals the patients choose to pursue (encour- givers should try to inform and motivate them. aging patients to become self-motivated). The purpose of the self-management support tools described in this report is to encourage Many people think that self-management sup- patients to become more motivated to adopt port is the same as patient education. However, healthy behaviors. If a patient chooses not to true self-management support involves both participate in health-related decisions, preferring patient education and collaborative decision that the clinician advise him or her what to do, making. Moreover, the education component the clinician has no choice but to make decisions of self-management support moves away from a on behalf of the patient but should check each didactic model of patient education toward an time to ensure that the patient agrees. Helping Patients Manage Their Chronic Conditions | 7 II. Five Strategies for Clinical Practice SELF-MANAGEMENT SUPPORT INVOLVES BOTH information giving
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